Hybrid Coronary Revascularization: Combining CABG and Stents for Optimal Outcomes

Jump To Section

• What is Hybrid Revascularization?
• Benefits of the LIMA Graft
• Limitations of Vein Grafts
• Advantages of Drug-Eluting Stents
• Patient Selection Criteria
• Logistical and Reimbursement Challenges
• Full Transcript

What is Hybrid Revascularization?

Hybrid coronary revascularization is a sophisticated treatment strategy for multivessel coronary artery disease. Dr. Jeffrey Popma, MD, describes it as a combination of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The procedure specifically uses the left internal mammary artery (LIMA) graft during surgery. Concurrently, drug-eluting stents are placed in other diseased coronary arteries. This integrated approach aims to provide the most durable revascularization result possible.

Benefits of the LIMA Graft

The left internal mammary artery is the gold standard conduit in cardiac surgery. Dr. Jeffrey Popma, MD, emphasizes its exceptional long-term performance. The LIMA to left anterior descending (LAD) artery graft is remarkably durable. It often remains patent for the entire lifetime of the patient. This superior patency rate is a cornerstone of the hybrid revascularization concept. It provides a reliable foundation upon which the rest of the treatment plan is built.

Limitations of Vein Grafts

In contrast to arterial grafts, saphenous vein grafts have significant limitations. Dr. Jeffrey Popma, MD, explains that veins are frequently used for circumflex and right coronary artery targets. However, their long-term durability is considerably lower. Vein grafts may only remain patent for approximately 10 years. They often occlude sooner due to degeneration and disease within the graft itself. This high failure rate is a primary driver for seeking alternative strategies like hybrid revascularization.

Advantages of Drug-Eluting Stents

Modern drug-eluting stents offer a compelling alternative to vein grafts. Dr. Jeffrey Popma, MD, notes their excellent long-term durability. The performance of contemporary stents is often better than that of saphenous vein grafts. By stenting non-LAD arteries, the hybrid approach avoids the inherent weaknesses of venous conduits. This combination leverages the best available technology from both interventional cardiology and cardiac surgery.

Patient Selection Criteria

Identifying the right patient is crucial for a successful hybrid procedure. The ideal candidate typically has multivessel coronary artery disease. They benefit from a LIMA-to-LAD graft for the critical anterior heart wall. Their other lesions should be suitable for stenting with drug-eluting stents. This strategy is particularly valuable for patients where full arterial grafting is not feasible. Dr. Jeffrey Popma, MD, highlights that this approach delivers the most durable long-term results for suitable individuals.

Logistical and Reimbursement Challenges

Implementing a hybrid revascularization program involves significant coordination. Dr. Jeffrey Popma, MD, discusses the practical hurdles. A key decision is the timing of the stenting procedure relative to surgery. Teams must decide whether to perform PCI before the patient goes to the operating room or afterwards. Furthermore, reimbursement presents a major challenge. The payment models for combining a surgical procedure and a stenting procedure performed concurrently are not yet fully established. Despite these hurdles, Dr. Popma confirms the topic remains very important for advancing patient care.

Full Transcript

Dr. Anton Titov, MD: What is hybrid myocardial revascularization? Which patients with coronary artery disease benefit most from hybrid myocardial revascularization procedures?

Dr. Jeffrey Popma, MD: The concept of a hybrid myocardial procedure is important. It comes from this fact. The left internal mammary artery to the left anterior descending artery is a fairly durable operation.

Dr. Anton Titov, MD: It potentially and oftentimes does last the patient's lifetime.

Dr. Jeffrey Popma, MD: The number of graft failures that we have with the LIMAs is much less than what we have with veins. In contrast, in patients that have disease of the left circumflex or of the right coronary artery, oftentimes veins are placed as grafts. Veins are used as grafts if there are no arterial conduits available.

Those veins may last 10 years in a patient with coronary artery disease. Vein grafts also may occlude after 10 years and sometimes even before that time because of degeneration of the vein graft itself.

The concept of a hybrid myocardial revascularization is this. The surgeon would do bypass surgery with the left internal mammary artery, with the LIMA. Other coronary arteries in a patient with coronary artery disease would be stented with drug-eluting stents.

We know that the long-term durability of the drug-eluting stents is pretty good. It is better than revascularization with vein grafts. The hybrid myocardial revascularization concept would give the patients the most durable long-term results. It will treat coronary artery disease much better.

The problem is always reimbursement. How do you pay for the stenting procedure? How do you pay for the surgical procedure? Because they are all done at the same time. We haven't really worked that out.

The fact that it takes a little bit more coordination, a little bit more time to do. Do you do coronary artery stenting before the patient goes to the operating room? Do you do the stenting afterwards?

Dr. Jeffrey Popma, MD: We have done it both ways. But it is a very important topic. It is a topic that we will think about more.

We think about how we are going to effectively treat patients with aortic valve disease as well. Who benefits from a combination of open heart surgery and coronary artery stent placement? Coronary artery bypass grafting, CABG.